Cardiac Shear Wave Elastography: Principles, Clinical Applications, and Practical Considerations for Interpretation

Cardiac shear wave elastography (SWE) is an emerging ultrasound-based technique that enables noninvasive assessment of myocardial mechanical properties beyond conventional motion- and deformation-based indices. By tracking the propagation of shear waves within the myocardium using ultrafast imaging, SWE provides stiffness-related information that may complement standard echocardiographic parameters in selected clinical settings. In this narrative review, we summarize the methodological principles of cardiac SWE, including acoustic radiation force-induced techniques, natural shear wave imaging approaches, and emerging three-dimensional SWE. We discuss current clinical evidence in key disease states characterized by altered myocardial stiffness, such as hypertrophic cardiomyopathy, cardiac amyloidosis, heart failure with preserved ejection fraction, and post-transplant or diffuse myocardial injury. Importantly, SWE measurements are highly context-dependent and influenced by cardiac phase, loading conditions, myocardial anisotropy, imaging plane, and acquisition methodology. Therefore, reported values should be interpreted as reflecting stiffness-related myocardial behavior rather than direct measures of fibrosis or specific histopathologic substrates. At present, cardiac SWE remains primarily a research-stage technique, with potential roles in phenotypic characterization, disease burden assessment in selected populations, longitudinal monitoring, and future integration into multiparametric echocardiographic and artificial intelligence-assisted workflows. Further standardization, definition of normal reference ranges, technical validation, and multicenter clinical studies are required before broader clinical adoption. In conclusion, cardiac SWE represents a promising extension of echocardiographic assessment of myocardial mechanics, but its clinical interpretation requires careful consideration of methodological, physiological, and disease-specific determinants.